Specialists miss health care reform

MEDICARE rebates for patients of specialists should depend on the specialist writing a report on the referred services, says a professor of general practice.

Writing in the latest MJA, Professor Tim Usherwood, professor of general practice at the University of Sydney, also called for more incentives for non-GP specialists to bulk bill concession card holders and children. (1)

Professor Usherwood said such incentives would help address the financial barriers that prevent many patients from attending specialists.

He cited Australian Bureau of Statistics data showing that 10% of Australians delayed or missed their specialist appointment due to cost. (2)

There were currently no Medicare incentives for specialists to bulk bill for most consultations, Professor Usherwood wrote.

Dr William Glasson, president of the Royal Australian and New Zealand College of Ophthalmologists and a former AMA president, agreed with Professor Usherwood’s proposal that specialists should have to write a report to access Medicare rebates.

“I completely support that … part of what you’re being paid for is to write a report back to the referring doctor. It should be mandatory”, he told MJA InSight.

However, the current AMA president, Dr Steve Hambleton, said that making doctors write a report in order to access Medicare rebates was not the way to improve communication between GPs and specialists.

“Using a Medicare rebate to ensure quality communication is a blunt tool that is likely to lead to more red tape … and we don’t need any more red tape”, he said.

He said the AMA had a policy on referrals within the profession, which contained detailed guidelines for communication between specialists. (3)

Suggestions that there should be incentives for specialists to bulk bill were difficult because Medicare rebates were insufficient to cover the costs of providing specialist care.

“Suggesting that they should bulk bill is suggesting that they should match the rebate, which is not enough to provide quality care”, he said.

Dr Glasson agreed that Medicare rebates did not reflect the costs of quality care and said the most important thing was to increase the value of these rebates.

He suggested Medicare rebates could be differentiated depending on the type of patient, and praised the recent introduction of a new item number (109) for paediatric ophthalmology patients.

“You could argue that there may need to be differential rebates for those who can least afford it”, he said.

In the MJA article, Professor Usherwood said that private specialist practice was the “forgotten sector” in health care reform, despite the fact that $1.6 billion of the Medicare budget flows to these services.

“The current health care reform process is remarkable for its lack of attention to private non-general practice specialist services … the lack of a comprehensive policy framework means that access to private specialist services is determined largely by market forces”, he wrote.

He said a bulk-billing incentive may be more socially just than the current Extended Medicare Safety Net (EMSN) and referred to data showing that most of the EMSN benefits go to people in more well-off areas. (4)

Dr Glasson, who helped establish the EMSN when he was AMA president, agreed that the safety net needed work but said there was no need to “throw the baby out with the bathwater”.

“The principle is right but there are some excesses that need to be addressed, and we need to ensure that those people who can’t afford health care are being picked up”.

14 thoughts on “Specialists miss health care reform”

If I read this report correctly, is it true that some specialists don’t send reports back to the referring GP after seeing a patient?

If so I am shocked.

This is part & parcel of proper, ethical care. Surely we don’t have to resort to financial incentives to get some specialists to fulfil their professional obligations to a patient? That is tantamount to professional misconduct and should be treated as such, negating the need for financial or any other incentives.

Speciaists charge 3 to 4 times what a bulk billing GP charges
They spend about 30 mins minutes with each patient with some specialists spending much less time, eg, dernatologists. I have many patients who go from specialist to specialist as they cannot find a diagnosis or cure for their condition. The cost can be enormous.There is an enormous disparity between what the generalists – the GPs – can charge compared with what the specialists can charge. GPs have barely time to define the real cause behind the presenting symptoms because longer times spent with patients can be penalised by Medicare, so it is only the specialists who can spend these longer times with the patient.

Jules, we have a 0.5FTE staff member that spends her entire shift chasing feedback from specialists and hospitals. Here in Canberra we have some specialists who flatly refuse or just ignore requests for feedback. I have told patients that I refuse to refer to such practitioners as I consider it an unsafe practice if they do not provide feedback. The problem is a limited pool of certain specialities so sometimes you have no choice but to refer to them.

‘Medicare’ is dead. There is no point in tinkering at the edges (although the politicians either do not know that, or will not admit it). Private specialist services (charging private fees) had a ‘ceiling’ for the first 15 years. The patient could be seen in the relevant public hospital outpatient clinic, and receive specialist care. But waiting lists and waiting times have blown out, as state governments have refused to maintain public hospital funding to keep up with demand. There is immense irony in the comment coming from a Canberra GP. Canberra is a two level economy. The upper level not supported by mining, but by public service incomes. Obviously the funding accruing to the ACT Territorial Government is insufficient for the needs of the Canberra public hospitals. Neither Canberra’s politicians nor its public servants are prepared to address that issue. (Since, almost uniformly, they carry private insurance and are treated in Canberra’s private hospitals. Canberra is a microcosm of the rest of Australia. Having ‘diagnosed’ the problem, the Labor Party’s solution is SuperClinics, Medicare Locals, Lead Clinician Groups, and Hospital Networks. Multiple bureaucracies costing money. The Liberal Party’s response, in power, will be to shrug its shoulders. This is the Brave New [Medical] World, we might as well get used to it.

As a psychiatrist I used to bulk bill all pensioners and health care card holders – but only until the mid 1980s when the rebate began to fall so far behind the reasonable fee it was no longer viable. By 2005 a bulk-billing psychiatrist would have earned LESS per hour than a bulk-billing GP. I know, as I did the calculations then.
Those GPs who think ALL specialists are better paid then GPs are very wrong. Procedures pay, consultations don’t, regardless of what your field is!
As for rebates being linked to writing a “report”, be very careful of what Medicare may then chose to define as a report. I always wrote a brief, but informative, letter to the GP on the day, or rarely within a few days, of first seeing the patient, and after any change in management. That was what they said they wanted when I discussed it with them.
If Medicare demanded reports of the type dictated for management plan items like 291, which take more than an hour to do, certain specialties would be vacated fast. I never used that item again after the first one took me far too long to do in a manner that complied with Medicare’s specifications. The GPs I knew said they didn’t want all that detail anyway.
Never let academics dictate practice as it plays into the bureaucrats’ hands..

Now the issue of other incentives. GPs have been encouraged to computerise billing and record keeping with grants. Specialists never get them and, as many specialists don’t work in groups of sufficient size to share the cost of compterisation, it has been slow being adopted. I started using a computer for billing in 1987 and went over to full record keeping on computer in 2002. But that was because I am the technical type, and ran an IT business on the side anyway. Mind you, there are a lot of solo GPs and small GP practices that are barely computerised. In Melbourne in 2007 I surveyed the 260 plus GPs referring to me about their interest in going over entirely to online communication and only two practices expresses any interest..

I completely agree with Rob the Physician and RayT the psychiatrist. Medicare rebates would not come close to covering the cost of running my practice. It’s a different matter for proceeduralists who can happily bulk-bill rooms consultations because they generate much more income from doing their procedures.
Remember the Relative Value Study that found that Medicare rebates for both GPs and non-procedural specialists should be doubled? The then treasurer, Peter Costello, merely said that he didn’t have the money and the RVS is still gathering dust on a shelf somewhere.
When I started in private specialist practice I used to bulk-bill all pensioners and health care card holders. Now I won’t bulk-bill at all. I lost track of the number of health care card holders I saw driving expensive cars and having overseas holidays every year.
The concept of “free medicine” as promoted by Medicare bulk-billing has resulted in many patients expecting not to pay fees for private medicine and generally taking the medical profession for granted, and at times treating medicos and their staff with rudeness and even contempt.
Quite seriously, I would retire from clinical practice before I would accept any bribes or bow to any coercion to bulk-bill.

What is with the poll?
The answer is, I will not bulk bill in my private clinic because I do not believe in bulk billing. Option 3 seems to indicate that incentives are not needed, ie. bulk billing can occur without incentives.
I am happy to see pensioners and health care card holders in my public hospital clinics, and will bulk bill in my hospital-based private clinics (where overheads are mostly covered) but these clinics may not last for much longer- if we end up being forced out into private practice for all ambulatory consultations, no more bulk billing, public patients will have no choice.

As a supposed procedural specialist, I could never afford to bulk bill patients on any where near the current rebate. Procedures are performed in my practice on less than 5% of patients, yet my patients get the same rebate as specialists who operate on over 50%. A “non procedural” gastroenterologist gets a medicare rebate at more than twice the rate I do. In my practice the reduced fees charged to health card holders and pensioners are subsidised by other patients, other wise ends just would not meet. Bulk billing I couldn’t pay my insurance and staff costs. The RVS showed a major overhaul was needed, and this is still the case.

Bulk billing is simply accepting what the govt thinks you’re worth…..any small business manager will tell you 1)you’ll slowly go out backwards (as I did by charging less than I should have done) and 2)maintain your professional self esteem by charging what you think is a reasonable fee…..I think someone with 25 years experience should be charging more than someone fresh out of school)…..funny someone should mention the RVS…..it’s some 15 years ago now, the govt was so shocked at the financial implications they just ignored it…..and that was the conservatives……

What a lot of rot. Specialists are being paid way over the top for thier services compared to GPs. Half their luck. Why should they bulk bill. GPs who bulk bill have found that their “pay for service” has shrunk to nothing. Which specialist in his right mind would want to see his pay for service be tied to this kind of payment.

We must maintain the process that a GP refers to a specialist who then provides advice back to the GP on the diagnosis and ongoing management. If communication is poor, don’t refer to that specialist. Don’t keep sending for 2nd and 3rd opinions.
Medicare is ineffective in subsidising specialist services. It’s a sad joke. Patients need to realise the amount of rebate they get is a disgrace and they are being brainwashed to think that medical & healthcare is ‘free’. Unfortunately, if they can’t afford the service, queue up at a public hospital outpatient clinic to see doctors in training.

Any specialist who says they cannot cover their costs and make a very comfortable living when bulkbilling pensioners, retirees, etc, even if they account for more than 50% of their patients is being disingenuous. We have a privileged recession-proof job and many others don’t. The Medicare rebates however are not increasing with inflation and there is therefore some cross-subsidy from the paying patients – this is as it was before Medicare when some less well off patients were treated “honorary” – so we can’t blame the system.